ISRAELI DOCTORS AND HUMAN RIGHTS

498 FOOD IRRADIATION group of the International Unions (IOCU) at the IAEA/FAO/ food irradiation held in Geneva in December, 1988, we write to clarify some of the issues raised by Dr Kaferstein (Feb 4, p 280). He suggests that the safety of irradiated food and concern about the abuse of irradiation to conceal contamination on unfit food were dealt with in the final resolution of the conference. This is untrue. The resolution did refer to the need for all food to be subject to good manufacturing practice and for effective quality control throughout food processing, storage, transport, and retail sales; and it notes that "irradiation should not be used as a substitute for [hygienic] practices". However, this obscures the fact that the conference could not reach consensus on a workable definition of what that means in practice. Consumer representatives sought agreement on the need for international microbiological standards for foodstuffs and a clear statement that the application of good manufacturing practice and effective hygienic practices would preclude irradiation of any food with a level of bacterial contamination exceeding these microbiological standards. However, some government representatives argued that good practice should be interpreted as including the use of irradiation to reduce high bacterial contamination on foods to levels that would permit sale. Such use of irradiation is at the heart of cases of abuse1 which IOCU circulated at Geneva but which the conference managed by procedural manoeuvres to avoid discussing. Your Jan 7 note on the conference was correct in identifying this issue as one reason why the IOCU observer group disassociated itself from the final statement. Consumers have indicated that development of food irradiation be postponed until methods for detection of irradiation have been developed. A Marplan opinion poll for the London Food Commission in January, 1987, showed that 93% of those polled thought that the UK ban on food irradiation should not be lifted until detection tests were available. The 12th international congress of IOCU in Madrid in 1987 passed a resolution on similar lines. In a statement from a former health minister, Mrs Edwina Currie, on Feb 8,1988, the UK government recognised the need for additional controls to prevent abuse. The working group established by the London Food Commission in 1985 has argued that a new regimen of testing for the underlying bacteriological problems which can be concealed by irradiation will be needed.1 The refusal of the conference to accept the need for new tests or for microbiological standards reinforces the concern of many consumers. If the principle of preventing irradiation of unsaleable foods is not accepted consumers will have every reason to ask "If a food has had to be irradiated what was wrong with it?" Despite Kaferstein’s assertion about the safety of irradiating food the matter remains controversial. IOCU represents 170 consumer bodies in several countries: in 1987 it unanimously called for a moratorium on irradiation. Our concern stems not, as Kaferstein suggests, from confusion with radioactive contamination or from a "natural opposition to food irradiation" but from a detailed and reasoned critique of the way the safety evidence has been dealt with. The Geneva conference rejected Kaferstein’s proposal that the conference statement include an assertion that "all safety standards have been resolved". IOCU distributed a paper on "outstanding questions on the safety of irradiated food", but the response from an ad hoc committee avoided many of the key issues. IOCU has yet to see from WHO a response to criticisms2 of the 1988 WHO

SIR,-As members of the observer

Organisation of Consumers WHO/ITC conference on

publication. WHO should produce a comprehensive, balanced, accurate, and properly referenced report on all aspects of safety instead of attempting to misrepresent the views of consumer bodies. The Geneva conference should have been allowed to hear and respond to

the detailed criticisms from consumer bodies. Instead it was addressed on "Consumer acceptance of irradiated foods," by J. Taylor, a private individual representing no consumer body. Her paper indicated a dangerous contempt for the concerns of the consumer movement over the past four years. If Dr Kaferstein feels that IOCU was "permitted to participate much more actively than is normally the case in meetings of

representatives" it is high time that there were new that guarantee a better balance between consumer and other interests in all such UN sponsored events. The international discussion of pesticide issues is a precedent. government structures

London Food Commission, 88 Old Street, London EC1V 9AR

TONY WEBB TIM LANG

1. Webb

T, Lang T. Food irradiation, the facts. Wellingborough: Thorsons, 1987: 85-87. 2. IOCU Regional Office for Asia and Pacific. Critique of the 1988 World Health Organisation publication Food Irradiation a Technique for Preserving and Improving the Safety of Food (Geneva: WHO, 1988) Penang, Malaysia. IOCU, Dec 1988.

ISRAELI DOCTORS AND HUMAN RIGHTS

SIR,-Last year I was flooded with requests to inquire into incidents that seemed to offend humanity and medical ethics. I read memoranda from organisations taking an interest in affairs in Israel and the occupied territories, and studied your Round the World column. The Israel Medical Association (IMA) has voiced its concern to the authorities, especially the Ministry of Defence and the Israel Defence Forces (IDF), and has received clarification of every case brought to its attention. IMA’s concerns have been to improve medical services and to prevent harm stemming from breaches in international conventions; to ensure that physicians do not participate in any task that contravenes medical ethics; and to prevent the detention of physicians or paramedical personnel for fulfilling their professional duties. Happily, Israel is a democracy in which every case can be investigated. News media are on the spot and it is unlikely that anything is kept secret. Health care in the occupied territories could be improved but it is already better than care in most surrounding countries and is an advance on the situation before 1967 in the Gaza strip (Egypt) and the West Bank (Jordan). In Gaza, pre-1967 infant mortality was over 140 per 1000 live births; in 1975 it was 85 and in 1987, 30. Despite the violence the sick and the injured continue to receive medical care locally and referral to hospitals in Israel when necessary. Israeli doctors hold consultative clinics and help physicians and paramedical teams in medical education and try to raise prevention and treatment to Israeli levels. What are sometimes referred to as "demonstrations" in the occupied territories reflect nothing short of a state of war. My inquiries show that the orders given to Israeli soldiers comply with international conventions. There is irregular behaviour but to the best of my knowledge all incidents are looked into and, when necessary, the soldier is punished. The army does not try to cover up such misdeeds, and it shows films portraying irregular behaviour with the aim of deterring soldiers from departing from high standards. I have examined, with the civil and military authorities, evidence for toxic effects from tear gas. The IDF uses CS gas, not CN. CS has been widely used in western countries and animal studies have revealed no embryotoxic or teratogenic effects. Claims about miscarriages in the West Bank and the Gaza Strip were not based on scientific data. A Royal Commission, appointed to inquire into the use of CS in Northern Ireland, concluded that widespread use of CS does not increase miscarriage or stillbirth rates or lead to congenital abnormalities. The operational orders of the IDF prohibit the use of CS in confined spaces. In your Round the World column of Oct 29, 1988 (p 1012), Dr Kandela claims that there is evidence that some Israeli doctors are "directly involved in the ill-treatment of detainees and in the use of torture." Such allegations cannot be disregarded. There is, however, no basis for Kandela’s claim. To the best of my knowledge no Israeli doctor, civilian or military, participates in the interrogation of detainees. Kandela’s article astounded me because it was written so that the reader could not distinguish between fact, imagination, and prejudice. I have never met Kandela. He visited Israel, like other people who claim to be on a "fact-fmding mission", but made do with data that matched his preconceived position. I suggested a meeting but he did not have the time and made do with a telephone call, quoting from it only a vague phrase which does not express reality. The IMA does proclaim concern about the medical

499 treatment of detainees: we

did so in the past and will continue

to

do

irrespective of questions from overseas and even though most cases brought to our attention prove groundless. The 1984 letter from Mr Raja Shehadeh, mentioned by Kandela, is one example of an allegation found to be without substance. We will continue to inquire into all allegations, whether they arise out of genuine concern or from adopted positions that no fact will change. so,

107 Feltham Hill Road, Ashford, Middlesex’i’W15

President

to

reply

to

the last

paragraph

of Dr

SIR,-All the evidence I gave for the alleged involvement of Israeli physicians in the interrogation of detainees was obtained from human rights organisations, whose continued credibility depends on the accuracy of their reports. One such organisation is Law in the Service of Man (Al Haq), which is the West Bank affiliate of the International Commission of Jurists. Early in 1984 Al Haq investigated several allegations against doctors. On May 2 its director, Mr Raja Shehadeh, wrote to the president of the Israeli Medical Association listing three ways in which, it was alleged, Israeli doctors had been involved in the interrogation of detainees-namely, advising Israeli interrogators "on particular points of weakness in the health and body of the person being interrogated" and "on the detainee’s ability to sustain further interrogation" and participating directly in interrogation "by falsely stating that if the detainee does not confess and receive immediate treatment the consequence for his health could be

permanently damaging". AI Haq asked the IMA to investigate these reports but on June 7, 1984, the IMA issued a press statement accusing Al Haq of "malicious and libellous accusations" against Israeli doctors. Al Haq responded by confirming that it has "evidence of the participation of individuals representing themselves as physicians in prisoner interrogation". It threatened to make this evidence public, but at that stage the Association of Civil Rights in Israel offered to act as an intermediary. Al Haq passed the evidence to them on Aug 8 for transmission to the IMA. The IMA referred the papers to the IDF Medical Corps who declared the allegations groundless. Dr Ishay cites this as an "example of an allegation found to be without substance". The way the matter was handled casts doubt on that conclusion. Interest in the case extended beyond Israel and the West Bank. On Sept 24, 1985, the secretary of the British Medical Association (BMA) asked Mr Niall MacDermot, secretary-general of the International Commission of Jurists, for information on the

subject, and this was provided. Since then, more cases have been reported, as related in my article. All information included was based on sworn affidavits obtained by human rights organisations. The cases of Mr Omar Kamel Dabbour and Mrs Naila Ayish came from Al Haq. Information about Mrs Mariam Ismail was passed to me independently by the Centre of Alternative Information in West Jerusalem and the Tel Aviv based Women’s Organisation for Political Prisoners. I met several former detainees who described experiences similar to those documented by the human rights organisations. In its 1988 annual report, Al Haq stressed that in collecting affidavits it regards hearsay evidence as inadmissable. Such human rights organisations are not infallible and they are often accused of bias by the governments they criticise. However, their reports are generally taken seriously. I have no doubt that the vast majority of physicians in Israel adhere to the highest level of ethical standards. Several have spearheaded campaigns in Israel and outside to highlight abuses of human rights and deficiences in health care in the occupied territories. However, the actions of a small minority can tarnish the image of the majority. Medical ethics should be judged not only by the actions of the majority but also by the willingness of that majority to face up to and deal with any problems within its ranks. Ishay was helpful when I telephoned him-indeed it was he who alerted me to the fact that a military doctor was to stand trial for neglecting his duties at an army camp in February, 1988, which

PETER KANDELA

IHH

REFORM OF LAW ON ABORTION

RAM ISHAY,

Israel Medical Association, Tel Aviv 64928, Israel

***We invited Dr Kandela Ishay’s letter.-ED. L.

resulted in the death of a Palestinian youth. I used that information in my article and am sorry that he now says that all I took from my conversation was "a vague phrase which does not express reality".

SIR,-According to the Independent (Feb 17, p 8), Mrs Thatcher is contemplating legislation to reduce the fetal age at which abortion is legal to 24 weeks. If the reform is restricted solely to this aim it will be welcomed by supporters of abortion as much as by the anti-abortion lobby. The danger is that once the issue is brought before the House of Commons attempts will be made to reduce the limit below 24 weeks and to restrict access to abortion in other ways. At present abortion is legal to 28 weeks but is prohibited within the private sector after 24 weeks by regulations from the Department of Health and is not knowingly performed after this stage within the NHS. A legal restriction to 24 weeks would not alter clinical practice and would bring our law into line with that of other countries. The Abortion Act makes no mention of an upper time limit. The limit of 28 weeks derives from the definition of fetal viability under the Infant Life Preservation Act 1929, which defmed the earliest stage of pregnancy at which it was then considered that the fetus might be capable of life independent of the mother. Abortion of all types is defined by fetal loss up to this stage of viability. Since 1929 resuscitative techniques have greatly improved and there is general agreement that 24 weeks would now be appropriate and acceptable. The law needs altering because of medical progress. It would seem logical and efficient to continue to allow abortion up to the age of viability (since otherwise there will be problems in classifying fetal loss in the stage between 24 and 28 weeks) and the obvious course is for Parliament to reform the Infant Life Preservation Act. 10 Campden Hill London W8 7LB

Square,

PETER DIGGORY

MORBIDITY OF VERY-LOW-BIRTHWEIGHT INFANTS

SIR,-Dr

van

Zeben-van der Aa and

colleagues (Feb 4,

p

253)

report on morbidity of very-low-birthweight infants and claim that "handicap" was unrelated to birthweight. But their data can be

interpreted otherwise. van

Zeben-van der Aa misuse the

term

handicap-they

mean

disability or impairment. Those who manage these very-lowbirthweight infants should minimise the handicap for a given disability. This point is not germane to the relation between disability and birthweight, nevertheless it bears reiterating because it is the essence of tertiary prevention. The definitions by which they classify disabilities as minor or major are imprecise. A minor disability is equated with "mild neurological disorder such as a slight hemiparesis or quadriparesis, mild visual or hearing defects, or moderate psychosocial problems". What do slight, mild, or moderate mean? Many paediatricians would argue that any quadriplegia is a major disability. Paediatricians and general practitioners did the follow-up examinations of these children; was there any assessment of inter-observer variation? A validation exercise of paediatric neurologists examining children with cerebral palsy showed considerable variation between them in allocating the cases to mild, moderate, or severe categories.1 It is reasonable to assume that inter-observer variation is lower in children with a major rather than a minor disability. That being so, an examination of major disabilities among survivors by birthweight in table v suggests that the rates increase with decreasing birthweight. In the groups below 750, 750-999, 1000-1249, 1250-1499, and 1500 g or above, the major disability rates among survivors were 0/18, 10/112 (8-9%), 16/257 (6-2%), 21/383 (5-5%), and 12/199 (6-0%), respectively. The two groups that do not fit in with a birthweight effect are at the extremes of the birthweight range. In the children below 750 g the survivors are so few that the 95% confidence interval for those with disability must